1346618063 NPI number — THERESA A BROCKMAN LISW

Table of content: THERESA A BROCKMAN LISW (NPI 1346618063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346618063 NPI number — THERESA A BROCKMAN LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKMAN
Provider First Name:
THERESA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346618063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
424 WARDS CORNER RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45140-6966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-576-7700
Provider Business Mailing Address Fax Number:
513-576-1020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1231 COLUMBUS AVE UNIT A1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45036-8196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-695-4495
Provider Business Practice Location Address Fax Number:
513-228-1236
Provider Enumeration Date:
09/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  I1451226 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0165638 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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